In the winter of 2014, I met Leo Kline at the Translating Identities Conference at the University of Vermont in Burlington. He and Rachel Inker, a physician at the Community Health Centers of Burlington, were giving a workshop on the state of trans-competent healthcare for Vermonters. This past month, Leo took some time out of his schedule to share his perspectives on providing queer and trans healthcare.

GMC: Will you share a little about yourself and the work that you do?

LK: I just started my position as a nurse practitioner at the Community Health Centers of Burlington. Previously I worked there as a nurse and even before that I worked there as a medical assistant, so I have some pretty good longevity at that clinic. I got my Masters of Science in Nursing in January, my role as a primary care provider. I hope to serve the LGBTQ population and provide a safe space for people to come and get care that's informed and affirmative. I've pitched that to the folks that hired me as one of my goals and they were very receptive. I think that support is pretty unique, certainly in rural healthcare, so I feel privileged to be working there.

GMC: How did you arrive at nursing?

LK: In college I was an athletic trainer's assistant, and enjoyed that work enough to get EMT training. In college I studied printmaking and other visual arts. I worked in different studios in Colorado and Massachusetts but unfortunately developed a repetitive nerve injury from doing the manual labor of printmaking. I had to switch careers at that point and thought back on my time as an AT assistant and EMT. I started working on an ambulance with a rescue squad in Richmond, Vermont. The medical field was a good fit for me, so I applied and was offered the position of medical assistant at CHCB. I loved the people and the work, and I thought ok, this is what I'm meant to do. I went back to school at the University of Vermont to be a nurse practitioner while working at CHCB.

GMC: Will you tell us about the trans clinic you work at, how it came into being, who it serves, and why it's so awesome?

LK: The main clinic is a federally qualified health center. It is very large, with many providers, a functioning lab, and a number of off-site clinics, including two homeless clinics, one for youth and one for adults and families. There's a practice on Pearl Street that, on Thursdays, is specifically a trans clinic. Dr. Rachel Inker and myself worked to get it up and running in 2010. We started it out as a pilot to see if there was the need, and it was very successful. It became very popular and has actually overflowed that spot, meaning Dr. Inker has to see people who would probably preferred to see there at the Pearl Street location, up at the main clinic instead. The hope is that is that I will meet some of that need and provide other avenues for trans patients and also anyone who might fit under the LGBTQ umbrella. I would like to broaden the scope of what we provide to encompass more of the queer community. That's one of my goals, and Dr. Inker and the medical director is all for it, so we can be really supportive to each other in that way.

GMC: Will you talk a little bit about makes a queer-competent clinic?

LK: I think there's a big picture view and then the minutiae of what creates an affirmative space. The big picture view would be that all staff involved in the care of queer patients would have some level of training and comfort with language and the needs of the population. It’s important to talk about how to create a safe space, including things we think would be difficult and try to problem-solve as a group. Awareness of one’s own biases and having an openness to talk about some of these complex beliefs is also important. For example, some of the patients are very out and proud about their trans identity and other people live a very stealth existence, where they would prefer others not to have any knowledge of that part of their life.

So the provider, nurses and front desk staff might work together on how to create a space that is safe and acknowledging of both of those perspectives. The main clinic is a pretty busy bustling place, there's a big waiting room, while our little clinic on Pearl Street has two exam rooms, and there's a handful of staff there. It's much less intimidating in a way. Whoever's at the front desk needs to be very comfortable with different gender presentations and exhibit an attitude of non-judgment, which we are very fortunate to have with the people we currently work with.

More obvious manifestations of a safe space include stickers that say safe space, a queer flag, and having handouts that are appropriate to the population. Once people get to the exam room, we need to be comfortable discussing all aspects of healthcare, so that means providers and nurses need specific training. Attending conferences that focus on queer health, learning risks and behaviors and health outcomes, and studying the data to plan how best to meet the needs of the population. So training is involved both at the clinic itself and beyond that. We also offer a social worker onsite, who can meet with people who are in any form of distress or who need to discuss resources. It's a very holistic model of care.

GMC: I read a little bit of your graduate thesis online. Will you talk about your research?

LK: My study tried to understand if Nurse Practitioners who watched a short video of trans folks talking about their healthcare would express more desire to learn the guidelines of treating trans folks or express more interest in treating trans folks, as compared to a group of NPs who hadn't seen the video. The study gave some information but no statistical significance could be drawn due to low response rates to my survey. What I did learn, though, was that the majority of the people sampled had not learned about the guidelines and were willing to learn more.

GMC: I'm struck by the word comfort. A provider may not know the actual protocols or guidelines around trans healthcare, and whether they are interested in or motivated to learn or do the research to become more competent may have to do with how comfortable they are with gender and sexuality. Even if a provider has the appropriate language, the patient can really sense if the provider is uncomfortable.

LK: Absolutely. I think it's about being willing to walk through that discomfort and ask for feedback from the patients, get your feet wet and reach out to other providers. It is a different part of medicine in some ways, and in other ways it isn't at all, no more complex than talking to a young woman about birth control. In some ways you have to have a different sensitivity and awareness that many mainstream people may not be thinking about. To a provider who is swamped with a million things, that might feel intimidating. If they don't seek the training, they may feel underprepared, and end up referring people to a different provider. That was what I was grappling with when I wrote my thesis: what makes somebody say, "Hey I should take the time to learn more about this." I thought hearing a trans person on the video say "I deserve healthcare just like anyone else" might sway a provider to do some introspection and ask, "Why couldn't I provide this?"

GMC: Was there any training around queer health care in your nursing program?

LK: Yes. I wouldn't say it was extensive. We had one training covering all of LGBTQ health, not super trans-specific. I know that the med school at UVM is working toward incorporating more training too, so we're sort of on the cusp of having more attention paid to these issues. There's definitely room for improvement.

GMC: Why do you choose to do this work?

LK: I want be present for the LGBT folks that need it. I see that many people in that community fall through the cracks because they don't feel comfortable in a healthcare setting, so its important to me to be a person who is openly inviting anyone from that community to come and get safe care, that their values and needs will be respected. I recently wrote my bio for my new job, and looking through the bios of my colleagues, I noticed that Dr. Inker is the only other person who mentions transgender medicine in the bio. To me it is important to have providers say outright that they are there for different populations, and I'm happy that I can provide that for someone. Who knows, just reading that bio could be a turning point for a queer or trans person to decide to seek care.

GMC: It occurs to me that there are a lot more healthcare options for folks who are not queer than there are for LGBTQ folks, especially in rural areas.

LK: Exactly.

GMC: Do you think your experiences serving LGBTQ communities has had any influence on your capacity or thinking around serving other marginalized communities?

LK: Well, working with diverse populations has been imbedded in my upbringing. CHCB serves a very diverse population. Basically what it comes down to is being open, doing some homework, not expecting somebody else to teach you who they are and where they come from, not faking that you know more than you really do, having a willingness to be humble and ask questions, being respectful. I think those are important things for serving any diverse population.

GMC:I'm an herbalist and you're a nurse practitioner. Do you have any ideas or opinions on the potential for integrative medicine meeting the needs of queer and trans patients or community?

LK: I would love that. I don't know how insurance companies would work with that –– the people that I work with are largely uninsured, underinsured, or insured by Medicaid, and I don't know how to get integrative care covered. I think many health conditions would benefit from a complementary approach of allopathic and naturopathic medicine. I think it would be amazing to have those options.

GMC: What would you tell practitioners who are wanting to provide more or better care to trans patients? Resources?

LK: Do some research and introspection. Get comfortable with the topics surrounding LGBTQ care. You could go to the CDC website, the website for the Transgender Center for Healthcare Excellence, or even do simple Google searches to learn about what's hot right now in transgender healthcare.

Do some introspection, ask yourself what you might do in various situations unfamiliar to you. What's coming up for you? Queer people are all around us, and it would be beneficial to have a game plan and have some knowledge to back that up. The deer in headlights does not go over so well with patients. Basically do some research and think about what your beliefs are around transgender identity and health.

Another thing would be to start creating a network of people. If you know of another provider who has familiarity with caring for gender-variant individuals, why not have a conversation with them? You might ask if they would consult with you when needed. Having a contact may decrease the feeling of isolation. Isolation can become prohibitive to wanting to provide the care. But there are other providers out there offering care to the LGBTQ community, so start reaching out. I think we need to start connecting with each other, there are practitioners all over the state who would benefit.

GMC: Do you have any advice to offer queer and trans patients seeking care?

LK: I think Pride Vermont has a health care provider list. They are a very open organization and easy to talk to. For folks who are younger, Outright Vermont has drop-in clinics, and I know a few of the folks who work there, and they are amazing. It's a safe space to put your feelers out and get some support and learn about resources by word of mouth. It's pretty powerful, for queer people or any vulnerable population, to hear someone they know saying they had a great experience with a provider. I think the personal recommendation carries a lot more weight than getting a list of providers.

In the exams rooms themselves, if folks are feeling like their needs aren't being met or they feel they are being mistreated, feedback needs to be given. I think that can be intimidating, but if you feel mistreated, the organization would likely want to know about it. Maybe the providers themselves are unaware that they have offended the person. If an individual feels that a provider isn't knowledgeable about their needs, they can either verbalize this to the provider and say, "Is there any possibility that you can learn more about this, or do you recommend that I see someone else?" Clearly state your needs. That's what I really hope someone would do with me, if they felt like they needed some more support.

One thing that I've seen is that sometimes trans folks have been waiting a really long time to seek care and to actually address the trans identity needs they have, and for those folks it can feel very frustrating to come in and not have everything addressed in one visit. For example, they may come in, out themselves to their provider, and express a desire to begin hormones. I think there is a frustration that can occur when people can't start on hormones at that visit. So one of the things I'm thinking is that it would be helpful for that person to try to have an openness to the process of transition that lies ahead. This is something we want to work with them on, we want to be safe and treat them appropriately, and that can take a little bit of time. It's not that we are trying to delay their transition, it's that we want to be careful and thorough and not cut any corners, and that is what you would want from really good health care provider.